Forum Focus – Eliminating Preventable Harm in the ICU

This article first appeared on Wing of Zock ( on October 18, 2012.

By George Bo-Linn, MD

We must eliminate all preventable harm to patients that happens in health care.

Your reaction to that statement is likely to be, “That’s a no-brainer!” or to challenge that lofty goal and to ask for a measurement, a percentage, of harm that we could prevent. I’ve had a lot of conversations that have followed these lines of thinking over the past few weeks, and I’m still saying the same thing: We must eliminate all preventable harm — because none of us can point to the patient whose harm we won’t prevent.

I’m having these conversations as I lead a new effort, a national Patient Care Program at the Gordon and Betty Moore Foundation. Our founders are committed to advancing positive change for our planet and the people on it. That is why they’re supporting this new program focused on improving health care for adults in the United States. They’re also upping the ante: When we talk about our goal to eliminate all preventable harm, we’re not just speaking of medical harm. We’re also talking about the patients’ loss of dignity and respect, also a preventable harm and all too common in health care.

You’ve seen the data: Almost half of patients report a loss of dignity and respect when interacting with the health care system. Only half of patients are presented with treatment choices or asked their opinions. A quarter of hospitalized patients report that clinicians failed to explain medications prior to administering them.

Reflecting on this information and building on what we’ve learned from the foundation’s nursing care work to date, we’ve developed an approach — a theory of change — that could make it possible to achieve our goal of eliminating preventable harm, beginning in acute care settings. The theory focuses on developing a health care system that changes in two specific ways: First, by meaningfully engaging both patients and families so that they plan an active role in health care; and second, by revamping the system itself to optimize the way that teams, processes, and technology could work together better to prevent harm and to involve patients and their families.

We see these two goals as inextricably linked. How else can we ensure safe, affordable, compassionate health care unless we actively involve patients and their families as true partners in the redesign of its delivery? If we make progress as anticipated, as we partner with other like-minded individuals and organizations, the foundation will invest half a billion dollars over the next ten years in the Patient Care Program.

One of our founders, Gordon Moore, is the cofounder of Intel. His experience leads him to encourage taking big risks. We know that big risks have the potential to lead to big ideas and big wins — in this case, for patients and their families. We believe that we’re moving down that path with the development of this new Patient Care Program, and we’re starting in a health care setting that’s as harried as they come: the ICU. One of the foundation’s first Patient Care Program grantees is the Johns Hopkins Armstrong Institute for Patient Safety and Quality. Here, Dr. Peter Pronovost will lead an effort to change the way the ICU works and eliminate preventable harm, and that will include the meaningful involvement of patients and their families.

Consider the potential for preventing harm in the ICU. In nearly every other industry, technology has been able to improve the quality of work and lower costs, but that hasn’t been the case in health care. Sadly, we hear stories like the one of Leah Coufal, a 12-year-old girl who died of respiratory arrest while narcotics, intended to relieve her pain, slowed her breathing until she stopped. Separate equipment dripped the narcotics into her system and monitored her breathing, instead of working together through a connected system. Technology failed here.

Let’s take it a step further to consider how the system could better connect with health care professionals. If those pieces of equipment were connected, they could sound an alarm to alert a clinician. Or a clinician could have entered information into an electronic health record that connected to this equipment and directed it to work together.

A health care system should not hurt its patients. It should prevent avoidable complications, errors, waste and disrespectful care. Those preventions also will reduce health care costs. Every moment we delay, more people are hurt, and more of us lose the joy that our profession can bring.

George W. Bo-Linn, MD, is the chief program officer for the Gordon and Betty Moore Foundation’s Patient Care Program and the San Francisco Bay Area Portfolio. He can be reached at